Retrograde popliteal approach for challenging occlusions of the femoral-popliteal arteries

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Antegrade ipsilateral subintimal angioplasty for recanalization of the superficial femoral arteries (SFAs) has a failure rate of 10%-20%. We report our initial experiences performing recanalization of the SFA or popliteal artery (PA) in cases of failed antegrade angioplasty using a medial infracondylar retrograde popliteal approach with the patient supine. Between February 2010 and December 2011, 19 patients with chronic total occlusion of the SFA and/or proximal PA (mean occlusion length, 20.5 ± 5.54 cm) underwent transpopliteal procedures after failure of an antegrade procedure. Upon failure to re-enter the true lumen distal to the occlusion during initial antegrade recanalization with the patient supine, a medial retrograde popliteal access at the infracondylar plane was adopted, without turning the patient (with the leg in a 60° external rotation and the knee in a gentle flexion). Puncture of the distal PA was guided fluoroscopically and a guidewire was inserted into the true lumen, after which retrograde recanalization proceeded in accordance with standard protocol. Once the occlusion was crossed from distal to proximal, the wire was advanced through a 6F sheath in the common femoral artery. The preferred approach for angioplasty and stenting was from the femoral artery. Hemostasis at the popliteal access was achieved by combined intraluminal balloon dilatation and manual compression (3-5 minutes). The mean follow-up period was 8.6 ± 4.1 months and included measuring the ankle-brachial index and duplex ultrasound. Technical success (puncture of the PA and SFA recanalization) was achieved in all cases. All but one patient received stent implantation from the antegrade approach. Sheaths were used in five (26%) patients; four patients were treated with a 4F sheath and one with a 6F sheath. There was one (5.26%) major complication (a popliteal access site occlusion) and two (10.5%) minor complications (small hematomas in the popliteal region). The primary patency at 6 months was 84.2%. The medial infracondylar retrograde popliteal approach with the patient in the supine position can be considered safe and efficient for recanalization of the SFA or proximal PA after failure of an antegrade approach.